Showing papers by "Stephen G. Pauker published in 1982"

On the Elicitation of Preferences for Alternative Therapies

Abstract: We investigated how variations in the way information is presented to patients influence their choices between alternative therapies. Data were presented summarizing the results of surgery and radiation therapy for lung cancer to 238 ambulatory patients with different chronic medical conditions and to 491 graduate students and 424 physicians. We asked the subjects to imagine that they had lung cancer and to choose between the two therapies on the basis of both cumulative probabilities and life-expectancy data. Different groups of respondents received input data that differed only in whether or not the treatments were identified and whether the outcomes were framed in terms of the probability of living or the probability of dying. In all three populations, the attractiveness of surgery, relative to radiation therapy, was substantially greater when the treatments were identified rather than unidentified, when the information consisted of life expectancy rather than cumulative probability, and when the problem was framed in terms of the probability of living rather than in terms of the probability of dying. We suggest that an awareness of these effects among physicians and patients could help reduce bias and improve the quality of medical decision making.

Mild Head Trauma in Children: When Is a Roentgenogram Necessary

Abstract: Review of 354 infants and children who had skull roentgenography for head trauma over a 21/2-year period revealed a low incidence of fractures (4.2%) and no serious intracranial complications. With the exception of one patient with an elevated surgically depressed skull fracture, treatment was not changed because of the detection of a fracture. Thus, in the usually mild head trauma sustained by most children, routine skull roentgenography is inefficient. To make efficient use of resources, clinical criteria are necessary to select patients for skull roentgenography. Criteria previously defined for adult patients are, however, less useful in children. On the basis of the present study, additional criteria were identified so that fractures may be detected among children with mild head trauma, at much reduced cumulative cost and exposure to radiation. Nevertheless, the clinical importance of detection of skull fractures remains uncertain.

Local effects of electrical and mechanical stimulation on the recovery properties of the canine ventricle

Abstract: The effects of electrical stimulation on local recovery properties of the canine ventricle were studied. Ventricular excitability was examined by an analysis of unipolar or bipolar strength-interval curves, and the effective refractory period was derived from the steep portion of the curve. Conduction times of all propagated responses to testing stimuli were recorded. When ventricular driving and testing sites were the same, effective refractory periods were significantly shorter (probability [p] Thus, shortening of the effective refractory period and prolonged conduction in the vicinity of the driving electrode are a function of stimulus intensity, distance from the driving site and time. These local alterations in the recovery properties of the ventricle provide conditions that may be favorable for the induction of reentrant arrhythmias.

Idiopathic nephrotic syndrome in a 53-year-old woman. Is a kidney biopsy necessary?

Abstract: A 53-year-old woman was admitted to New England Medical Center with nephrotic syndrome. Nine years earlier, she had been found to have a blood pressure of 150/110 mmHg. At that time her 24 hour protein excretion was 900 mg, her blood urea nitrogen was 18 mg/dl, and her serum creatinine was 0.9 mg/dl. She was given propranolol and achieved good control of her blood pressure. One year before admission her protein excretion increased to 2.8 grams/24 hours and her serum creatinine was 1.1 mg/dl. At that time both the antinuclear antibody titer and the lupus erythematosus preparation

Rational Diagnosis and Treatment: An Introduction to Clinical Decision-Making

Abstract: Although clinical decision-making occupies a central role in the practice of medicine, the basic principles of this art have, until recently, rarely been discussed, formally taught, or subjected to the well-deserved scrutiny applied to most aspects of medical care. This brief, more or less readable book attempts to give both student and practitioner an armchair view of medical logic. The first edition might have served to introduce the preclinical student to uncertainties commonplace in the clinic; unfortunately, the second edition delivers far less than the reader must invest, hardly providing a modern view of a rapidly evolving field. After reading this monograph, the student will certainly appreciate the nature of clinical reasoning and the flaws that all too often make it irrational. Wulff delineates the problems but fails to provide reasonable approaches to their solution. In fact, he dismisses the entire field of prescriptive decision-making: "I hope that no clinician

Abdominal pain, atherosclerosis, and atrial fibrillation. The case for mesenteric ischemia.

Abstract: DT, a 63-year-old white male with insulin-dependent diabetes mellitus and severe peripheral vascular disease, was admitted with a five-day history of vague abdominal pain and diarrhea. On the day of admission he vomited three times, was noted to have a bloody stool, and came to the emergency room. DT denied hematemesis, fever, or chills. He had bilateral leg amputations and had sustained three myocardial infarctions, the last one 15 months before this admission. He had never experienced symptoms of abdominal angina. Of significance was his history of congestive heart failure, mitral regurgitation, and atrial fibrillation. His medications on admission included digoxin 0.25mg per day, furosemide 40mg per day, and NPH insulin 15 units per day. On admission to the hospital his oral temperature was 38 degrees C, pulse was 90/min, respiratory rate was 24/min, and blood pressure was 134/80mmHg. Abdominal examination revealed a distended abdomen with hypoactive bowel sounds and mild tenderness. Chest x ray revealed cardiomegaly. The electrocardiogram demonstrated atrial fibrillation. A plain film of the abdomen was positive for gallstones and edema of the bowel wall (thumb-printing). Laboratory results included blood urea nitrogen 48mg%, creatinine 1.2mg%, hemoglobin 18g/dl, and hematocrit 52.9%. White blood cell count was 11,900 cells/cc with 33% polymorphonuclear leukocytes, 47% bands, 8% lymphocytes, 11% monocytes, and 1% atypical lymphocytes. The prime considerations for differential diagnosis were mesenteric ischemia and infectious gastroenteritis. While it was appreciated that mesenteric ischemia, if present, might warrant surgical intervention, the risk of anesthesia itself in this patient was felt by his attending physicians to exceed 30%. Furthermore, the clinical findings were only "suggestive" of mesenteric eschemia. They were certainly not "diagnostic." In view of this dilemma, a consultation with the Division of Clinical Decision Making was requested.

Evaluation for colon cancer in patients with occult fecal blood loss while taking aspirin: a Bayesian viewpoint.

Abstract: This paper examines the implications of occult fecal blood loss in patients taking aspirin (at least 2 grams daily). Although such patients do have a somewhat higher probability of colonic carcinoma than do members of the general population, their risk is far lower than that of patients who have gastrointestinal blood loss when not taking aspirin. This difference in risk exists because aspirin itself can provoke occult blood loss in stool. Patients who manifest gastrointestinal blood loss while taking aspirin can be separated into two groups, based on whether or not that blood loss continues after aspirin is discontinued. Although patients who continue to bleed are at high risk for colonic carcinoma, those who cease having any blood loss are at lower risk than are members of the general population. Further diagnostic studies to detect colonic carcinoma should be pursued in the former group, but not in the latter, low-risk group.

Recurrent endocarditis in a patient with a permanent transvenous pacemaker.

Abstract: rary pacer was inserted, followed under antibiotic coverage four days later by insertion of a Coratomic Model L500 permanent pacemaker. Postoperatively, the patient developed fever and phlebitis at the site of the temporary pacing wire. The electrode was removed, and oxacillin was given for a total of six days. The patient was discharged three days after discontinuation of that therapy. One year prior to this admission, a manufacturer’s recall necessitated elective replacement of BK’s pulse generator. A CPI Model 505 was implanted and connected to the old electrodes. The patient experienced no postoperative complications. Four months prior to this admission, the new pacemaker failed, demonstrating complete loss of capture. The pacer’s output was therefore increased. One month later, BK was admitted with fever, chills, and syncopal episodes of ten days duration. Six blood cultures were positive for Staphylo-

Elective surgery in the setting of comorbid anesthesia risk. Timing of cholecystectomy in a patient with Graves' disease and hepatitis.

Abstract: EM is a 46-year-old woman with symptomatic cholelithiasis and multiple medical problems. Eight years prior to the present admission she underwent a total proctocolectomy, ileostomy, and right salpingo-oophorectomy for granulomatous colitis. Since that time she has had many abscesses and draining sinus tracts, necessitating surgery, although she has experienced no further symptoms of gastrointestinal distress. One month ago EM suffered an episode of non-A, non-B viral hepatitis, with her bilirubin level peaking at 11.3 mg/dl and subsequently returning almost to normal. At the present time she has slightly elevated serum levels of aspartate aminotransferase (SGOT), alanine aminotransferase (SGPT), lactate dehydrogenase (LDH), and alkaline phosphatase. At the same time as the diagnosis of hepatitis was made, she was found

Clinical Decision Making Rounds At the New England Medical Center

Abstract: In this Clinical Decision Conference we address an obstetrical management problemdetermining the optimal timing for the delivery of a monoamniotic, monochorionic twin pregnancy. This unusual form of twinning exposes the fetuses to the special risk of entanglement of their umbilical cords. The literature delineating the relation between the length ofgestation and the cumulative probability of that obstetrical catastrophe is sparse. Although careful pathophysiologic reasoning might suggest that early delivery would be indicated, such iatrogenic prematurity would engender a substantially increased likelihood of perinatal morbidity or mortality, especially because a twin pregnancy would likely produce fetuses whose weight would be lower than those of singleton fetuses of comparable gestational age. The analysis focuses on the relation between the marginal changes in these risks as a function of time. The analysis also highlights the potential disparity between the frequency of adverse